# Situation: A nurse runs the weekly immunization session of a Barangay Health Station (BHS) under the National Immunization Program (NIP) and reviews the station's target client list. A 14-week-old infant comes for the third doses. The mother reports that 3 days after pentavalent 2, the infant became unresponsive for several hours and was admitted; the hospital diagnosed encephalopathy and found no other cause. The infant is now well. Which plan is CORRECT today?

> source: MyMerci (mymerci.kr)  
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> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: A nurse runs the weekly immunization session of a Barangay Health Station (BHS) under the National Immunization Program (NIP) and reviews the station's target client list.

A 14-week-old infant comes for the third doses. The mother reports that 3 days after pentavalent 2, the infant became unresponsive for several hours and was admitted; the hospital diagnosed encephalopathy and found no other cause. The infant is now well. Which plan is CORRECT today?

## 보기

1. Give pentavalent 3, bOPV 3, PCV 3, and IPV 1 as scheduled
2. Withhold all vaccines until the infant turns 1 year old
3. Withhold pentavalent 3; give bOPV 3, PCV 3, and IPV 1 **✔ 정답**
4. Give pentavalent 3 after a dose of paracetamol; give the rest

**정답: 3**

## 해설

Encephalopathy within 7 days of a pertussis-containing vaccine, with no other cause, is a contraindication to further doses of that vaccine, so pentavalent (DTwP-Hib-HepB) is withheld; the physician completes diphtheria, tetanus, Hib, and hepatitis B protection with vaccines that have no pertussis component (for example, pediatric DT given with separate Hib and hepatitis B vaccines), which are not routine NIP stock. The contraindication applies only to the pertussis-containing vaccine; bOPV 3, PCV 3, and IPV 1 are due at 14 weeks and are given today.

## 심화 해설

Clinical situation

A 14-week-old infant is due for the third doses of the NIP schedule. The mother reports that 3 days after the second pentavalent dose, the infant became unresponsive for several hours, required admission, and was diagnosed with encephalopathy with no other identified cause. The infant is currently well.

Core principle

Encephalopathy occurring within 7 days after a pertussis-containing vaccine, without another identifiable cause, is a contraindication to further doses of that pertussis-containing vaccine. The pentavalent vaccine in the NIP contains a whole-cell pertussis component combined with diphtheria, tetanus, Haemophilus influenzae type b, and hepatitis B antigens. Because the pertussis component is the one linked to this serious neurologic adverse event, only the pentavalent vaccine is withheld. The other vaccines due at this visit do not contain pertussis and can be given safely.

Why option 3 is correct

At 14 weeks, the scheduled NIP vaccines are pentavalent 3, bOPV 3, PCV 3, and IPV 1. The contraindication applies only to the pertussis-containing pentavalent vaccine. bOPV, PCV, and IPV do not contain pertussis antigens, so they are not affected by this contraindication and are given today. The infant still needs protection against diphtheria, tetanus, Hib, and hepatitis B, but this is completed later using pertussis-free formulations such as pediatric DT with separate Hib and hepatitis B vaccines, which are not part of routine NIP stock and require physician-directed follow-up.

Why the other options are incorrect

| Option | Reason it is incorrect |
| --- | --- |
| 1. Give pentavalent 3 plus the rest | Repeating a pertussis-containing vaccine after vaccine-related encephalopathy risks recurrence of a serious neurologic event and is contraindicated. |
| 2. Withhold all vaccines until 1 year | The contraindication is specific to the pertussis component. Delaying bOPV, PCV, and IPV leaves the infant unnecessarily vulnerable to polio, pneumococcal disease, and poliovirus during a critical window. |
| 4. Give pentavalent 3 after paracetamol | Paracetamol may reduce fever or local discomfort but does not prevent or mitigate encephalopathy. It cannot convert a contraindicated vaccine into a safe one. |

Pathophysiology and clinical reasoning

The neurologic event described is consistent with vaccine-associated encephalopathy, a rare but serious adverse reaction historically linked to the pertussis component of whole-cell vaccines. The case report by Nergiz et al. notes that whole-cell pertussis vaccine has been held responsible for neurologic side effects and that the introduction of acellular pertussis vaccines significantly reduced these events [1]. In the NIP setting, the pentavalent vaccine uses a whole-cell pertussis component, which carries a higher risk of neurologic adverse reactions than acellular formulations. When encephalopathy occurs within 7 days of vaccination and no other cause is found, the temporal relationship and clinical presentation meet the standard criteria for a contraindication to further pertussis-containing doses.

Watch out! The 7-day window is the defining timeframe for this contraindication. A febrile seizure or hypotonic-hyporesponsive episode that occurs outside this window, or that has another clear cause, is managed differently. Here, the diagnosis of encephalopathy with no other cause places the event squarely within the contraindication category.

Key point! The contraindication is to the pertussis component, not to all vaccines. The nurse must differentiate between the pentavalent vaccine and the other NIP vaccines due at the same visit. bOPV, PCV, and IPV are not pertussis-containing and are administered as scheduled.

Nursing and program implications

The nurse at the BHS should document the adverse event clearly in the infant’s immunization record and flag the chart so that no future pentavalent dose is given inadvertently. The mother should be counseled that the infant still needs protection against diphtheria, tetanus, Hib, and hepatitis B, and that the physician will arrange for pertussis-free alternatives. The nurse should also report the adverse event through the national AEFI surveillance system, as serious neurologic events after vaccination require notification and investigation even when they are rare [1].

The longitudinal study by Long et al. reinforces that adverse reactions to DTP are monitored prospectively and that compliance with post-vaccination observation is high, but it does not alter the contraindication principle when a serious neurologic event is confirmed . The hexavalent vaccine review by Orsi et al. describes combination vaccines that include acellular pertussis, which have a more favorable neurologic safety profile, but these are not the same as the whole-cell pertussis-containing pentavalent vaccine used in the NIP . Provider attitudes toward pertussis vaccine, as surveyed by MacIntyre and Nolan, highlight the importance of understanding national guidelines on contraindications, which is exactly the clinical decision point in this scenario .

Summary of today’s plan

Withhold pentavalent 3 because of the contraindication to pertussis-containing vaccine after encephalopathy. Administer bOPV 3, PCV 3, and IPV 1 today, as they are due and safe. Refer the infant for physician-led completion of diphtheria, tetanus, Hib, and hepatitis B protection using pertussis-free formulations.References (research sources)

- [1]An infant who suffered seizures many times after pentavalent vaccination: A case report.Case reportNergiz ME, Yetisgin H, Aydin A, Bayhan GI, Kurt ANC. (2020) · DOI: 10.14744/nci.2019.50375

## 임상 시나리오

Pertussis-Containing Vaccine ContraindicationManaging the 14-week NIP visit after encephalopathy
Encephalopathy within 7 days of a pertussis-containing vaccine with no other cause is a contraindication to further pertussis vaccine doses only.

At 14 weeks, withhold pentavalent 3 but give bOPV 3, PCV 3, and IPV 1 as scheduled.

Complete diphtheria, tetanus, Hib, and hepatitis B protection later with pertussis-free formulations such as pediatric DT plus separate Hib and hepatitis B vaccines.

CautionDo not give paracetamol and then pentavalent; the contraindication is absolute for the pertussis component. Refer for non-routine vaccines not in NIP stock.

## 핵심 개념

- **Encephalopathy** — Severe brain dysfunction occurring within 7 days of a pertussis-containing vaccine with no other cause, a contraindication to further pertussis vaccine doses.
- **Pentavalent vaccine** — NIP vaccine containing DTwP-Hib-HepB; withheld after pertussis-related encephalopathy.
- **bOPV** — Bivalent oral polio vaccine; no pertussis component, safe to give.
- **PCV** — Pneumococcal conjugate vaccine; no pertussis component, safe to give.
- **IPV** — Inactivated polio vaccine; no pertussis component, safe to give.

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